Individual Insurance Market Rules in Massachusetts
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- Can insurance companies deny me coverage?
No. Insurance companies cannot deny you coverage in Massachusetts. All individual health insurance policies must be offered to all residents on a guaranteed issue basis year-round. This means that insurance companies are required to sell coverage to everyone who applies.
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- Can insurance companies charge me more than other people for the same policy?
In Massachussets, insurance companies can charge you more than other people for the same policy. However, the state has put some restricitons on how much the premiums can vary and on why they can charge more.
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- Can insurance companies exclude coverage of my pre-existing condition?
Insurance companies cannot permanently exclude coverage of your pre-existing condition in Massachusetts. Insurance companies cannot permanently exclude from coverage any health problems you disclose, or they find in your medical records, at the time of application by an amendment to the individual health insurance contract (called an “elimination rider”).
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- Can insurance companies make up their own definition of a pre-existing condition?
Insurance companies cannot make up their own definition of a pre-existing condition in Massachusetts. Insurance companies can only consider something a pre-existing condition if the person actually received medical advice, diagnosis, care or treatment for that condition prior to enrollment in the plan. This is called an “objective standard.
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- Can insurance companies accept my application for coverage and later search my medical records for an excuse to deny me coverage for needed care?
Insurance companies can accept your application for coverage and later search your medical records for an excuse to deny you coverage for needed care in Massachusetts. If you make a claim for health care services during the first 12 months (one year) of coverage, the insurance company can search your medical history dating back 6 months prior to the purchase of your policy looking for evidence that your current health problem was pre-existing. If the insurance company finds any such evidence, it can deny you coverage for that condition.
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- Can insurance companies pay their doctors incentives to provide me with less care?
Insurance companies cannot pay their doctors incentives to provide you with less care in Massachusetts. An insurance company cannot pay health care providers incentives to withhold covered care.
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- Can I appeal an insurance company’s denial of care to an outside entity?
You can appeal an insurance company's denial of care to an outside entity in Massachusetts. You can file an appeal for any denial of service to the Office of Patient Protection. The process costs $45. You must file an appeal within 45 days of final notice of denial by a health plan.
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- Can I sue my insurance company if it denies medically necessary care that causes me or a loved-one harm?
You cannot sue your insurance company if it denies medically necessary care that causes you or a loved-one harm in Massachusetts. You cannot sue an insurance company for any harm that may have resulted from its denial of coverage or benefits.
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SOURCE: Kaiser Family Foundation State Health Facts, 2007
To learn about all your rights and protections in the individual insurance market, contact the Massachusetts Division of Insurance.
